Strategies For Managing Nocturnal Awakening And Frequent Crying In Young Children

Challenges Faced by Parents with Nocturnal Awakening and Frequent Crying in Young Children

Question:

Discuss About The Nocturnal Awakening And Frequent Crying?

Nocturnal awakening and frequent crying episode in young children gives major challenges to parents while caring for their children. Bed time problem and night awakening affect about 20 to 30% of infants and toddlers. This problem initiating in infancy often persist in school age too. This is found to have deleterious effect on children such as poor cognitive development, mood problems, aggressive behavior and attention deficit. All this consequently has an impact on health and quality of life of children too. In case of parents, crying episodes and nocturnal awakening in children increases their distress level due to fatigue and lack of sleep (Honaker and Meltzer 2014) Hence, there is a need to find strategies or intervention to manage bedtime tantrums of children. The research by Rickert and Johnson (1988) identified the intervention of scheduled awakening as an effective strategy to reduce and gradually eliminate the crying episodes and night awakening in young children. The study mainly evaluated the effectiveness of scheduled awakening by comparing it with systematic ignoring procedure. The scheduled awakening intervention is the business process of waking and consoling a child 15 to 30 minute before nocturnal awakening to assist in sleep consolidation.  The maturation in sleep pattern was analysed by means including a no treatment group without the intervention too. This report critically analysed the research study by comparing it with recent literature on the same issue to assess whether such intervention should be funded or not. Hence, the decision for funding the intervention depends on its critical appraisal by means of relevant CASP tool

To analyse the effectiveness of scheduled awakening in reducing nocturnal awakening in young children, there is a need to review recent research literatures related to the topic to find out whether same strategies or other interventions has been proposed for addressing the research problem. The main strategy for searching the research article is to include only those articles which have been published between 2007 and 2017. The other inclusion criteria for articles includes they must be peer reviewed journal articles written in English and they must cover the strategies to manage nocturnal awakening in young children. The relevant research articles were retrieved from the databases like CINAHL, PubMed, Cochrane library and the search engine called Google Scholar. The key search term used in searching the articles included ‘nocturnal awakening and crying episodes in young children, ‘intervention for nocturnal awakening in infants’ and strategies to address nocturnal awakening issues in children’. The inclusion criteria and specific search term can help  to review current studies and evaluate current interventions proposed for the same issue.

Impact on Children’s Health and Parental Distress

The key findings from the review of literature are as follows:

Author and date	Intervention	Key findings
Honaker and Meltzer (2014).	It analysed the effect of behavioral interventions on bedtime problem and night awakening	Almost 94% studies reported efficacious outcome and clinical improvement in young children by using behavioral therapy. Support was given to interventions like scheduled awakening and positive routine
Meltzer and Mindell, 2014	Behavioral interventions like graduated extinction, parent education, bedtime fading, scheduled awakening was evaluated for their effect in sleep consolidation	Behavioral treatment resulted in improvement in children’s sleep onset latency and night waking frequency, however there is lack of studies that identified factors needed for success of treatment.
Vriend and Corkum, (2011)	Clinical management of behavioral insomnia	It explained about different form of interventions for behavioral insomnia such as pharmacological intervention, behavioral treatment and sleep treatments. Behavioral treatment was found to be the first in line treatment for the night awakening
Werner et al. (2015)	The Zurich 3 concept for the management of sleep disorder in children. This process combines the sleep regulation model on introducing regular rhythm with adjusting bed time with behavioral strategies.	The intervention was found to decrease nocturnal wake duration of children and increase night sleep duration.
Price et al. (2012)	Evaluation of behavioral infant sleep intervention to improve infant sleep	Sleep intervention has no long term impact and parents can use their technique only for managing short to medium term sleep problems and maternal depression

As the research study by Rickert and Johnson (1988) is based on randomized controlled method, the CASP tool for randomized controlled trial has been applied for critically appraising the articles. The results of the appraisal are as follows:

Presence of focused issue in the study:

Rickert and Johnson (1988) gave clear indication of the focused issue in the study by clearly stating the main purpose of research. The main aim was to evaluate the effectiveness of scheduled awakening and systematic ignoring procedures (intervention) for decreasing awakening and crying episodes in infants and young children (population). Hence, the main intervention was scheduled awakening and systematic ignoring and the comparator was no treatment condition

Process of allocation:

In RCT studies, random allocation process is needed to randomly assign participants to treatment and control group. When this process is done correctly, it is effective in reducing bias in the system. Therefore, the two critical aspects of the random allocation process is developing random sequence and concealing the treatment before patients have been assigned to specific groups (Dettori 2010). The participants for the randomized controlled trial included 33 children with average age of 20 months and they were recruited via local newspaper advertisements. All the children were economy assigned to treatment group and control group before home visit (Rickert and Johnson 1988). Hence, it is confirmed that allocation sequence were concealed from researcher and patients as parents got to know about their assigned group only after data was collected regarding each child’s daily schedule (duration of time awake for the day, feeding time, duration when child spontaneously woke up and cried and unusual situations disrupting routine) for 9 nine weeks.

Treatment of patients who entered the trial:

To assess whether all participants who entered the trial were properly accounted for its conclusion or not, it is necessary that complete follow up of patient is done and researcher analyze the outcome in participants assigned to specific group. In this context, anomalies have been found in the treatment of group in the study. For instance, at first children were randomly assigned to control, scheduled awakening or systematic ignoring group. However, as many children dropped out in between, only 33 participants remained for the study out of 56. To ensure that all participants were analyzed in their assigned group, parents were asked to report seven days prior to treatment. This helped in maintaining baseline data for the study. The maintenance of baseline data reflects the validity and transparency of the study as it helps in effectively interpreting the study results (Deke and Puma 2013).

Strategies to Manage Bedtime Tantrums in Children

Blinding to treatment

Blinding in randomized controlled trial is done by having procedures that prevents participants and assessors from knowing which intervention was given to them. However, it is impossible to achieve blinding in studies, because for evaluating the outcome of the studies, active engagement of participants is required. In the research study by Rickert and Johnson (1988), all children and their parents were randomly assigned to treatment. This means allocation to treatment was concealed from them, however it cannot be said that they were blinded to treatment too. They were randomly assigned to control and the two intervention group and participants got to know about their assigned group only after data related to the history of spontaneous awakening in each child were collected. Hence, open labeling in this study was seen which did not fulfilled the blinding criteria and this may lead to biasness too. In a similar RCT study done to evaluate the effectiveness of behavioral sleep intervention, infants were selected on the basis of parents reported sleep problem, however the difference in approach from the above study was that allocation was concealed and only researchers but not parents were blinded to group allocation (Price et al. 2012).

Similarity of the groups at the start of the trial

While evaluating the quality of a RCT study, the similarity of the group at the start of the trial is denoted by baseline factors such as age, sex, social class, education and health status. Keeping these baseline parameters similar is critical for maintain the validity of the study because baselines factors also influence study outcome and effect of interventions (Higgins et al. 2011). Rickert and Johnson (1988) maintained the similarity of group at the start by taking children in the age group of 6 to 54 months. However, biasness in baseline factors was that same social factor was not maintained. For instance, there were single parent families as well as two-parent families. Difference in level of education of parents was also seen which might have great impact on the study outcome. Such baseline recruitment is not maintained in many other studies too.

Equal treatment of the group:

Equal treatment of the group in randomized controlled trial is maintained if researcher can identify any other factors apart from the intervention that might have an impact on performance on each participant. Rickert and Johnson (1988) equally treated the group by means of exclusion criteria for recruiting the participants. For instance, since two interventions- scheduled awakening and systematic ignoring was compared in this study, researchers took care to eliminate all those factors that could have an impact on interventions. Hence, the main consideration for the researcher was to exclude those parents who did not had concern regarding spontaneous awakening. Secondly, children who resisted in going to bed were excluded because scheduled awakening is not meant to address this problem and this could have an impact on study outcome. In addition, the researcher also analysed the baseline data for age and number of night awakening episodes to determine difference in groups according to baseline factors.

Effectiveness of Scheduled Awakening Intervention

Vastness of treatment effect

In RCT studies, treatment effect is understood from the method of comparison between outcome in intervention and control group. While comparing the decrease in the number of spontaneous awakening and crying episodes in each group, it was found that children in systematic ignoring group has faster rate of positive outcome in 8 weeks period. Another significant result from the study was that scheduled awakening was also considered to be effective in reducing night awakening, however the change or improvement in symptoms was slow in this case. The researcher also specified the period at which major difference in outcome in three groups were seen and this was observed mainly in week 3, 4, 5, 6  and 7 (Rickert and Johnson 1988). Hence, it can be said that be evaluating treatment groups in the order of intervention, the first place was taken by systematic ignoring condition followed by scheduled awakening and then the no treatment group. This result is also consistent with a study reviewing sleep management interventions as the study showed that systematically ignoring the demands of children for specific periods was effective in improving sleep patterns in children (Halal. and Nunes 2014).

Estimate of the treatment effect

The precision of the treatment effect in RCT studies is determined on the basis of confidence interval and effect size. This means that narrow confidence interval will denote clear precision in results, whereas wider interval is an indication of greater uncertainty in results. While evaluating Rickert and Johnson (1988) study on the basis of precision of its results, it can be said that the confidence interval is wide because great variability in control group and developmental trends were seen. This indicates that more research is needed to identify why children in no treatment group showed improvement in outcome. Despite this limitation, the study was successful in proving that systematic ignoring and scheduled awakening have positive effect in reducing sleep related behavioral issues in infants. Another study by ?rn?ec, Matthey and Nemeth, (2010) is most appropriate to justify this study outcome because the study was about the behavioral approaches of systematic ignoring and scheduled awakening only. The study proved the efficacy of the intervention.

The success of any research is understood when the research provided effective and validated evidence regarding applying the intervention is local population. The generalisability and transferability of a research is high if same intervention can be easily applied in local population. In the RCT study reviewing the effectiveness of systematic ignoring and nocturnal scheduling, it can be said that although systematic ignoring gave better outcome, however there is less chance of applying it in local setting. This is because many parents may not prefer ignoring their child’s cry as an appropriate treatment to reduce night awakening period. There is evidence also which have showed that parents strongly resist employing the systematic ignoring approach for their child (Etherton, Blunden and Hauck 2016). Hence, this fact suggest that scheduled awakening might be a better intervention to apply in local setting due its acceptance level  among parents compared to systematic ignoring. The limitation in acceptance of systematic ignoring also suggest that more research work is required to find effective alternative to ignoring that can give positive results too. There is also a need to conduct more research on understanding the mechanism to reinforce positive sleep behavior in children if systematic scheduling technique needs to be applied in the local population

Recent Literature on Strategies for Managing Nocturnal Awakening and Frequent Crying in Young Children

Consideration of clinically important outcomes

In the context of night awakening problem in children, the most clinically significant outcome was reducing the period of nocturnal awakening and frequency of awakening in children. Rickert and Johnson (1988) proved the efficacy of systematic ignoring and systematic awakening by means of clinical outcomes too. For instance, dramatic improvement in frequency of awakening in children was seen in the systematic ignorance group and the crying episodes were reduced in other intervention group. Hence, clinically also the study is outcome, however focusing on clinical outcome of parents like stress level post intervention would also have enhanced the validity and quality of the study

Value of the benefits from research

The RCT trial needed both cost and time investment, however this investment was worth the effort because the efficacy of both the interventions for children could be easily judged. The study gave honest response regarding the efficacy of scheduled awakening intervention compared to systematic ignoring on grounds of its viability and acceptance level by parents. However, the only limitation is that its effects are slower and identifying the correct mechanism for this intervention will improve the outcome associated with it.

Conclusion:

This report highlighted the issue of nocturnal awakening and crying episodes in children and it impact on both parent and child’s heath. The critical appraisal of the research by Rickert and Johnson (1988) along with comparison from recent research literature revealed that scheduled awakening is a beneficial strategy to reduce nocturnal awakening time in children. The literature search regarding similar topic also revealed that scheduled awakening is more favorable for reducing sleep problem in children. Hence, after realizing the efficacy of scheduled awakening intervention, it can be said that this intervention should be funded. It is also recommended to improve the mechanism associated with this intervention so that it can be easily implemented in community. More research regarding appropriate mechanism behind scheduled awakening would help to get clinical significant outcome in children and parents.

Reference

?rn?ec, R., Matthey, S. and Nemeth, D., 2010. Infant sleep problems and emotional health: a review of two behavioural approaches. Journal of Reproductive and Infant Psychology, 28(1), pp.44-54.

Deke, J. and Puma, M., 2013. Coping with missing data in randomized controlled trials. Mathematica Policy Research.

Dettori, J., 2010. The random allocation process: two things you need to know. Evidence-based spine-care journal, 1(03), pp.7-9.

Etherton, H., Blunden, S. and Hauck, Y., 2016. Discussion of extinction-based behavioral sleep interventions for young children and reasons why parents may find them difficult. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 12(11), p.1535.

Halal, C.S. and Nunes, M.L., 2014. Education in children’s sleep hygiene: which approaches are effective? A systematic review. Jornal de pediatria, 90(5), pp.449-456.

Higgins, J.P., Altman, D.G., Gøtzsche, P.C., Jüni, P., Moher, D., Oxman, A.D., Savovi?, J., Schulz, K.F., Weeks, L. and Sterne, J.A., 2011. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj, 343, p.d5928.

Honaker, S.M. and Meltzer, L.J., 2014. Bedtime problems and night wakings in young children: an update of the evidence. accounting respiratory reviews, 15(4), pp.333-339.

Meltzer, L.J. and Mindell, J.A., 2014. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. Journal of Pediatric Psychology, 39(8), pp.932-948.

Price, A.M., Wake, M., Ukoumunne, O.C. and Hiscock, H., 2012. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics, 130(4), pp.643-651.

Rickert, V.I. and Johnson, C.M., 1988. Reducing nocturnal marketing and crying episodes in infants and young children: a comparison between scheduled awakenings and systematic ignoring. Pediatrics, 81(2), pp.203-212.

Vriend, J. and Corkum, P., 2011. Clinical management of behavioral insomnia of childhood. Psychology research and behavior management, 4, p.69.

Werner, H., Hunkeler, P., Benz, C., Molinari, L., Guyer, C., Häfliger, F., Huber, R. and Jenni, O.G., 2015. The Zurich 3-step concept for the management of behavioral sleep disorders in children: a before-and-after study. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 11(3), p.241.